Introduction

Background
A pterygium is an elevated, superficial, external ocular mass that usually forms over the perilimbal conjunctiva and extends onto the corneal surface. Pterygia can vary from small, atrophic quiescent lesions to large, aggressive, rapidly growing fibrovascular lesions that can distort the corneal topography, and, in advanced cases, they can obscure the optical center of the cornea.

Pathophysiology
The pathophysiology of pterygia is characterized by elastotic degeneration of collagen and fibrovascular proliferation, with an overlying covering of epithelium. Histopathology of the abnormal collagen in the area of elastotic degeneration shows basophilia with hematoxylin and eosin stain. This tissue also stains with elastic tissue stains, but it is not true elastic tissue, in that it is not digested by elastase.

Frequency
United States Occurrence within the United States varies with geographical location. Within the continental United States, prevalence rates vary from less than 2% above the 40th parallel to 5-15% in latitudes between 28-36. A relationship is thought to exist between increased prevalence and elevated levels of ultraviolet light exposure in the lower latitudes. International Internationally, the relationship between decreased incidence in the upper latitudes and relatively increased incidence in lower latitudes persists.

Mortality/Morbidity
Pterygia can cause a significant alteration in visual function in advanced cases. They also can become inflamed, resulting in redness and ocular irritation.

Sex
Pterygia are reported to occur in males twice as frequently as in females.

Age

It is uncommon for patients to present with pterygia prior to age 20 years. Patients older than 40 years have the highest prevalence of pterygia, while patients aged 20-40 years are reported to have the highest incidence of pterygia.

Clinical
History
Patients with pterygia present with a variety of complaints, ranging from no symptoms to significant redness, swelling, itching, irritation, and blurring of vision associated with elevated lesions of the conjunctiva and contiguous cornea in one or both eyes.

Physical
A pterygium can present as any of a range of fibrovascular changes on the surface of the conjunctiva and the cornea. It is more common for the pterygium to present on the nasal conjunctiva and to extend onto the nasal cornea, although it can present temporally, as well as in other locations.

The clinical presentation can be divided into 2 general categories, as follows: o One group of patients with pterygium can present with minimal proliferation and a relatively atrophic appearance. The pterygia in this group tend to be flatter and slow growing and have a relatively lower incidence of recurrence following excision. o The second group presents with a history of rapid growth and a significant elevated fibrovascular component. The pterygia in this group have a more aggressive clinical course and a higher rate of recurrence following excision.

Causes

Risk factors for pterygium include the following: o Increased exposure to ultraviolet light, including living in subtropical and tropical climates o Engaging in occupations that require outdoor activities A genetic predisposition to the development of pterygia appears to exist in certain families. A predilection exists for males to develop this condition in significantly higher numbers than females, although this finding may represent an increased exposure to ultraviolet light in this portion of the population.

Differential Diagnoses
Squamous Cell Carcinoma, Conjunctival

Other Problems to Be Considered

Pseudopterygia (eg, chemical or thermal burn, trauma, marginal corneal disease) Neoplasia (eg, carcinoma in situ, squamous cell carcinoma, other neoplastic diseases) Pingueculae (ie, actinic lesions confined to the perilimbal conjunctiva that do not extend onto the cornea) o Pingueculae are commonly occurring, generally small and asymptomatic (often yellow) raised nodules appearing on the bulbar surface of the conjunctiva. They are found more commonly on the nasal side, but they can also present either on the temporal conjunctiva or on both the nasal and temporal conjunctiva in the eyes of some patients. o Pingueculae are thought to be associated with actinic (sunlight) exposure in susceptible individuals. o Pingueculae can occasionally be subject to some inflammation with symptoms of itching, burning, or mild pain. In the absence of inflammation or of significant cosmetic complaints, pingueculae are generally ignored (by patient and physician alike). If mildly symptomatic, like pterygia, they can be treated with artificial tears. o On rare occasions, ocular anti-inflammatory drops may be required. On even more infrequent occasions, surgical excision may be of benefit in the management of pingueculae. o Histopathologically, pingueculae show mild-to-moderate focal thickening of the conjunctival stroma with elastotic degeneration of collagen.

Workup
Imaging Studies

Corneal topography can be very useful in determining the degree of irregular astigmatism induced by advanced pterygia. External photography can assist the ophthalmologist in following the progression of the pterygium.

Procedures

Multiple different procedures have been advocated in the treatment of pterygia. These procedures range from simple excision to sliding flaps of conjunctiva with and without adjunctive external beta radiation therapy and/or use of topical chemotherapeutic agents, such as mitomycin C. Using free grafts of conjunctiva (with or without limbal tissue) at the same time as primary excision of the lesion has been widely advocated as the preferred treatment modality for aggressive pterygia. For moderate-to-severe pterygia, some corneal surgeons use amniotic membrane transplants. Both the conjunctival autografts and the amniotic membrane transplants may be sutured onto adjacent conjunctiva and subjacent cornea. Some corneal surgeons seal the graft tissue onto the underlying sclera with the aid of fibrin tissue glue rather than with sutures.

Treatment

Medical Care
Patients with pterygia can be observed unless the lesions exhibit growth toward the center of the cornea or the patient exhibits symptoms of significant redness, discomfort, or alterations in visual function. Pterygia can be removed for cosmetic reasons, as well as for functional abnormalities of vision or discomfort.

Surgical Care
Surgery for excision of pterygia is usually performed in an outpatient setting under local or topical anesthesia with sedation, if necessary. Postoperatively, the eye is generally patched overnight, and it is treated subsequently with topical antibiotics and anti-inflammatory drops and/or ointments.

Medication
Medical therapy of pterygia consists of over-the-counter (OTC) artificial tears/topical lubricating drops (eg, Refresh Tears, GenTeal drops) and/or bland, nonpreserved ointments (eg, Refresh P.M., Hypo Tears), as well as occasional short-term use of topical corticosteroid anti-inflammatory drops (eg, Pred Forte 1%) when symptoms are more intense. In addition, the use of ultraviolet-blocking sunglasses is advisable to reduce the exposure to further ultraviolet radiation.

Artificial tears (topical lubricating drops)

To lubricate the ocular surface and to fill in defects in the tear film. Artificial tears/topical lubricating drops (Refresh Tears, GenTeal [OTC]) Artificial tears provide topical ocular surface lubrication in patients with irregular corneal surfaces and irregular tear films. These conditions are very common in the setting of pterygium.

Follow-up
Further Outpatient Care

Postoperatively, after pterygium excision, the topical steroids are slowly tapered. Patients on topical steroids need to be observed to avoid problems, such as elevated intraocular pressure and cataracts.

Inpatient & Outpatient Medications

See Medication.

Deterrence/Prevention

Theoretically, minimizing exposure to ultraviolet radiation should reduce the risk of development of pterygia in susceptible individuals. Patients are advised to use a hat or a cap with a brim, in addition to ultraviolet-blocking coatings on the lenses of glasses/sunglasses to be used in areas of sun exposure. This precaution is even more important for those patients living in tropical or subtropical areas or for those patients

who are engaged in outdoor activities with a high risk of ultraviolet exposure (eg, fishing, skiing, gardening, outdoor construction work).

Complications

Complications of pterygia include the following: o Distortion and/or reduction of central vision o Redness o Irritation o Chronic scarring of the conjunctiva and the cornea o Extensive involvement of the extraocular muscles may restrict ocular motility and contribute to diplopia. In patients who have not yet undergone surgical excision, scarring of the medial rectus muscle is the most common cause of diplopia. In patients with pterygia who have previously undergone surgical excision, scarring or disinsertion of the medial rectus muscle is the most common cause of diplopia. In patients with significantly elevated pterygia, focal drying and subsequent thinning of the adjacent cornea may rarely occur. Postoperative complications of pterygium repair can include the following: o Infection o Reaction to suture material o Diplopia o Conjunctival graft dehiscence o Corneal scarring o Rare complications may include perforation of the globe, vitreous hemorrhage, or retinal detachment. Late postoperative complications of beta radiation of pterygia can include the following: o Scleral and/or corneal thinning or ectasia can present years or even decades after treatment. o Some of these cases can be quite difficult to manage. In some cases, adjunctive use of topical mitomycin-C at and after pterygium surgery has been reported to cause similar ectasia or melting of the sclera and/or the cornea. The most common complication of pterygium surgery is postoperative recurrence. Simple surgical excision has a high recurrence rate of approximately 50-80%. The rate of recurrence has been reduced to approximately 5-15% with use of conjunctival/limbal autografts or amniotic membrane transplants at the time of excision. On rare occasion, malignant degeneration of epithelial tissue overlying an existing pterygium can occur.

Prognosis

The visual and cosmetic prognosis following excision of pterygia is good. The procedures are well tolerated by patients, and, aside from some discomfort in the first few postoperative days, most patients are able to resume full activity within 48 hours of their surgery. Those patients who develop recurrent pterygia can be retreated with repeat

surgical excision and grafting, with conjunctival/limbal autografts or amniotic membrane transplants in selected patients.

Patient Education

Patients who are at high risk of the development of pterygia because of a positive family history of pterygia or because of extended exposure to ultraviolet irradiation need to be educated in the use of ultraviolet-blocking glasses and other means of reducing ocular exposure to ultraviolet light.

Miscellaneous
Medicolegal Pitfalls

As in any surgical procedure, careful informed consent must be obtained from the patient prior to surgery. While this procedure is fairly common with a very good visual prognosis in most patients, any ocular procedure can be associated with infection, perforation of the globe, vitreous hemorrhage, endophthalmitis, retinal detachment, or diplopia. Patients should be informed that redness and irritation may persist for longer than a month postoperatively. Patients should be informed about the chance of recurrence. The surgeon should check all biopsy results after excision of pterygium to rule out the possibility of an atypical presentation of a malignancy masquerading as a benign pterygium.